Manic or Hyperactive: What’s the Difference?

Helen, a 22 year old young lady, leans forward toward me — she is sitting in the chair I usually occupy during our sessions — and spills out details of an interaction with a customer she helped at her retail job. She speaks quickly and loudly and offers rich, often excessive details about what happened. I interrupt occasionally to ask for clarification or to redirect her back to our conversation about her medications, and she stops to answer my question but makes sure to come back to finish her story. Helen swivels around in the chair, she fusses with her bag and her phone case, and she often stretches her legs while talking. She moves or talks, or both, throughout our visit.

A few months earlier, Helen had been in the office and was overactive but at a completely different level. Instead of swiveling and fidgeting, she paced the room, often opening the door to the waiting room and pacing between there and my office. She left several times to pace outside and smoke a cigarette. She spoke so fast it was hard to understand her words, let alone follow what she was saying. She changed topics constantly and there was no space for me to redirect or ask for clarification. Her thoughts were full of ideas about religion and politics and the end of the world, and she told me she had come to understand things in a way that the whole world had to know, because she was the only one who had this figured out. Helen’s mood varied from happy and wildly excited to irritable in response to even minor frustrations or input from me. She had burst into a classroom at her college, planning to “teach” a class about her new insights and findings — that was when she was taken to the emergency room.

Helen’s most recent visit with me was typical for her. I have known her for a few years and this was her usual self. She is a super-energetic, highly animated young lady who has been diagnosed with and treated for ADHD since she was quite young. Sitting still and paying close attention in class or to homework were major challenges throughout her school years. She told me she always had lots of thoughts in her head and often felt like she could not keep up with them.

The visit a few months ago was the beginning of a manic episode — her first. She went into hospital and got started on medications for her bipolar disorder. Her ADHD medications were stopped, because they can make mania worse or be a trigger for manic episodes. Once her mood was stabilized, she returned to her usual high energy state.

High energy states can be part of several medical conditions, including ADHD or mania, but key differences distinguish the two.

The Big Difference between ADHD and Mania

Here’s the biggest difference between ADHD and mania:

In ADHD, the high energy is chronic and generally even. It may vary from day to day but only by typical ups and downs related to things like fatigue and stress. People with ADHD are always busy — often both physically and mentally.

Mania occurs episodically. By definition, it includes a change in energy that is different from the person’s baseline.

For Helen, even though her baseline is highly charged up, to those around her, the manic episode clearly looked and felt different from her usual patterns. Her pressured speech and racing thoughts were much more severe during this episode than they are when she’s not experiencing mania.

Other Differences between ADHD and Mania

A high energy manic episode differs from ADHD in several other ways. Such an episode is characterized by symptoms that may include:

A visible and sustained difference in mood — often excited or euphoric, but sometimes raging and angry.

Thinking is different — more disorganized and hard for listeners to follow or make sense of. Interrupting a person who is experiencing mania is nearly impossible.

The content of one’s expressions may be more typical of mania — with “grandiose” thinking that is often disconnected from reality — delusional or psychotic.

Judgment and impulse control, which are sometimes mildly impaired in ADHD, are profoundly disrupted and markedly change the person’s usual ability to make safe and healthy decisions.

Both high energy states can cause problems. ADHD hyperactivity often interferes with school, work, and relationships. But manic high energy, along with the changes in thinking and impulse control and judgment, are acutely and extremely damaging to life and day to day function. While the “charge” of the person with ADHD can have positive features such as passion and creativity, manic episodes so severely disturb thinking and behavior that any positives are vastly outweighed.

Accounting for Hyperthymia

People with bipolar disorder often have a high-energy baseline self, called hyperthymia. Often, even without ADHD, they’re full of energy and animation and ideas — this is their usual self. Their thoughts and bodies and moods may move and change gears quickly — but not at the same level or with the same damaging patterns as a manic episode. These qualities are not “pathology” themselves and are often positive and important parts of a person’s identity and life. Not everyone who is hyperthymic will develop bipolar disorder, and not everyone with bipolar disorder has a hyperthymic baseline.

Low energy is a common problem in our sleep deprived, anxious world. Depression and low “charge” are frequent complaints. Too much energy sounds like a dream come true to many, and it can be a positive, but it can also be dangerous. Teasing out different patterns of high energy is an important step in making correct diagnoses of psychiatric disorders — or in realizing there is no diagnosis at all.